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CA DHCS 6204 2021-2025 free printable template

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State of CaliforniaHealth and Human Services AgencyDepartment of Health Care Services WILL LIGHTHOUSE DIRECTORGAVIN NEWSOM Governorate Applicant: Thank you for your recent inquiry regarding participation
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CA DHCS 6204 Form Versions

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CA DHCS 6204 2021
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How to fill out CA DHCS 6204

01
Obtain a copy of the CA DHCS 6204 form from the California Department of Health Care Services website.
02
Fill out the top section with your personal details, including your name, address, and phone number.
03
Provide your Medi-Cal number if applicable.
04
In the next section, indicate your eligibility and income information as required.
05
Complete any additional sections relevant to your circumstances, such as dependent information or specific program selection.
06
Review the completed form for accuracy and completeness.
07
Sign and date the bottom of the form.
08
Submit the form according to the provided instructions, whether by mail, fax, or online submission.

Who needs CA DHCS 6204?

01
Individuals applying for Medi-Cal assistance.
02
Current Medi-Cal beneficiaries needing to update their information.
03
Those whose eligibility needs to be verified for health care services in California.
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CA DHCS 6204 is a form used by the California Department of Health Care Services to collect data related to the provision of health care services and to ensure compliance with state regulations.
Entities that provide health care services in California, including but not limited to Medi-Cal providers, are required to file CA DHCS 6204.
To fill out CA DHCS 6204, providers need to provide specific information about their services, billing practices, and compliance with state health regulations, ensuring all sections of the form are completed accurately.
The purpose of CA DHCS 6204 is to gather essential information for monitoring healthcare service delivery, ensuring accountability and compliance with state healthcare policies.
CA DHCS 6204 requires reporting on various aspects including provider details, services rendered, patient data, billing information, and compliance with health care regulations.
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